The last few weeks and indeed the month of June has seen a hive of activity in the world of policy and politics around health and social care. From the passing of the Care Reform Bill to the publication of the Health and Social Care Service Renewal Framework alongside the Population Health Framework there has been no shortage of meaty content for the policy and political anoraks to feast upon. Sometimes these actions can seem very distant from the delivery of care and support and even more so from the recipients of social care and health services. Just occasionally the words are worth taking note.

In what follows I want to reflect on some of the major events and key publications. Admittedly this is an initial reflection because I think it will take some time for the full range of ideas and plans to come to their fullest fruition.

The aspirations of the Health and Social Care Service Renewal Framework (2025–2035) are to be admired. Its aims are to take a fresh, strategic leap toward a future where Scotland’s health and social care are integrated, prevention-led, and digitally enabled. Few of us would find fault with this – grounded as they are on the almost forgotten work of the Christie Commission. They are anchored by five principles – Prevention, People, Community, Population, and Digital. Again, few would object to such a focussed analysis and the aspiration and tone which desires a decade of transformation.

Meanwhile, the Population Health Framework commits to closing health inequalities, shifting resources to upstream social determinants, and embedding place-based prevention. Together, these documents sketch a bold vision: health and care built not just for people, but around them.

I read both reports against the backdrop of the discussions I and others have been having which were contained in an Open Letter published in The Scotsman. This letter co-signed by leading clinicians and practitioners across health and social care in Scotland, and informed by Enlighten, argues that our system is “unsustainable, overly complicated, difficult to navigate” and goes on to demand long-term, collaborative reform.

I am therefore pleased that taken with the two published reports there seems to be an emerging ground for consensus and indeed collaboration.

The shared and consensual path forward seems to be growing, it is one which envisages:

• Shifting services upstream, reducing reliance on acute care, and investing in community-based surroundings – all hallmarks of smart, modern reform.
• Principled planning -moving from siloed service design to networked, population-focused approaches.
• Digital-first ambition – a necessary catalyst for efficiency, access, and personalisation.
• Cross-sector unity, echoed in the Open letter’s plea for independent, third sector and community partners to be full co-designers of reform.

There is real potential therefore in the work that has been and is being done, but it would be disingenuous of me to not also comment about what strikes me as being missing so far, not sufficiently emphasised and what steps, I believe, could make progress upon the shared aspirations more likely to succeed.

Bold though it is, the Framework underplays the significant contributive role which social care can deliver for Scotland and most importantly from my context for the health and wellbeing of all, not least older Scots. At times both documents are written too narrowly from an NHS centric lens – maybe inevitable given their origins, but I think they can also be improved by using a more communitarian and social care lens.

Take for instance Scotland’s world-leading and seminal legislation and basis of accessing social care, the Self-Directed Support (Scotland) Act (2013, amended 2025) and the new Care Reform (Scotland) Bill (passed June 10, 2025). Both I would suggest offer powerful mechanisms to enhance the Service Renewal Framework and the Population Health Framework – especially for improving care for older Scots in care homes and at home. Allow me to illustrate some examples:

Self‑Directed Support Act (SDS)

Choice and control are central and key principles of the way in which social care is delivered in Scotland. We have not always got it right and have not always adequately empowered those who use supports – but be that as it may – that these two principles are central is of very real importance and should not be brushed over or set aside. There was a long struggle to shape the SDS legislation and to base it on principles of greater personal autonomy, control, and empowerment. SDS enshrines the rights of people who receive care to shape how, when, and by whom it’s delivered – vital for older Scots wanting autonomy in diverse settings. The absence of its centrality in the new reports is more than disappointing.

One of the major goals of the new Framework is to re-align service provision – SDS if properly embedded (and not in the resource deprived and patchwork way of the moment) can genuinely shift services upstream by centring individual needs, supporting the Prevention, People, and Community principles of the Framework. The recently renewed statutory guidance for SDS can be used to extend SDS into care homes, enabling residents to even more than they do now to better direct elements of their own daily lives – activities, meals, visits – empowering both dignity and quality. Others and I have long argued that to limit the ability of older people in residential care to have full control through SDS is a limitation of their rights.

Then when we consider the Care Reform (Scotland) Bill again there are numerous and very real opportunities to bolster the reform goals.  This is most obviously the case in the new rights to respite for unpaid carers. Indeed, one of the glaring omissions of the Strategic Reform Framework is the virtual absence of recognition of the critical role unpaid carers pay in the whole health and social care economy. The new law mandates Councils to assess carers and provide funded breaks which aligns with the emphasis within the Framework upon prevention (by reducing burnout) and People (supporting caregiver health). It directly serves older Scots living at home.

The new Bill also furthers the aims of the new Frameworks in its emphasis on the continuity of care which secures stable care packages even if individuals move across local authorities -reducing disruption and supporting independence and long-term care planning, which is again in line with Population Framework aims.

But it is perhaps in the wider area of reform that there is an emphasis which can potentially help to properly achieve the aims of both the Frameworks. There is a real opportunity over the next few weeks and months for the whole system to build on the Bill’s emphasis on ethical commissioning, to embed Fair Work standards, sectoral bargaining, and clear progression ladders – all key to staffing stability across both home and residential care. And most obviously the significant digital and data achievements and innovations of aged care in both homecare and residential care have much to teach the wider acute, secondary and primary care communities.

The SDS Act and Care Reform Bill aren’t just legal formalities- they are levers to deliver the visionary ambitions of the Frameworks. When applied strategically, especially in care homes and homecare, they can drive real change, embed prevention, increase autonomy and frame stability and sustainability.

The Frameworks show we’re on track. The open letter tells us we have to be bolder, faster – and more inclusive. But without a social care turnaround and emphasis, I fear, this ambition remains incomplete. That will inevitably mean that we need political courage across the Parliament in making fiscal decisions that truly see the balance of care and support, move from the acute and secondary NHS hospital sector to community health and social care. We have talked about this for a long time and now we must see action rather than aspiration. How that is done and whether additional funding comes from re-alignment of other priorities is clearly a political decision, but the necessity of action should be inescapable. We cannot continue to see social care solely through an NHS lens, care and support in community offers true preventative advances and it is that we need to focus on rather than a singular obsessive focus on delayed discharge. Social care is more than that.

It is surely our mutual collaborative responsibility to now start to transform strategy into practice and go beyond grand vision to tangible improvement in the daily lives of older Scots. I am certain the independent and third social care sector is up for that task.

Donald Macaskill

Photo by Alex Skobe on Unsplash